Comparison of Curved and Straight Anchor Insertion for Bankart Repair

The quality of Bankart repair may be compromised by the presence of glenoid perforation during suture anchor placement. The purpose of this study was to compare the rate of glenoid perforation and biomechanical strength of antero-inferior suture anchors placed with a curved vs a traditional straight technique through an anteroinferior portal. Ten bilateral pairs of fresh human cadaveric shoulders were randomized to either a curved or a straight suture anchor insertion technique. An anteroinferior portal was used to place a 1.5-mm soft anchor in the anteroinferior glenoid (5:30 position for right shoulders). Anatomic dissection was performed, and the maximum load of each anchor was measured using a materials testing system. The overall rate of glenoid perforation by the anteroinferior anchor was 50%. The rate of glenoid perforation was 40% in the straight group and 60% in the curved group (P=.41). The median maximum load was 86 N in the straight group and 137 N in the curved group (P=.23). The median maximum load of the anchors that did perforate the glenoid was 102 N and of those that did not was 118 N (P=.72). The mode of failure was suture anchor pullout in all except one specimen. The curved guide was not superior to the traditional straight guide in terms of the rate of glenoid perforation or the maximum load of the suture anchors. Anterior cortical perforation of the glenoid during anteroinferior suture anchor placement is common with both techniques. [Orthopedics. 2019; 42(2):e242-e246.].

Arthroscopically Assisted Reduction and Internal Fixation of a Displaced Posterior Glenoid Fracture: A Case Report

CASE

We report the successful use of arthroscopy for reduction and internal fixation of a posterior glenoid fracture in a 62-year-old man 5 days following a skiing accident. Additionally, we review the technique utilized for successful fixation of this rare fracture, and we report the postoperative return of function.

CONCLUSION

Arthroscopically facilitated fixation of glenoid fractures has been reported in the literature with excellent clinical outcomes. However, arthroscopic reduction and screw fixation of a posterior intra-articular glenoid fracture (Ideberg type Ib), to our knowledge, has not been previously published. The unique benefits of arthroscopic screw fixation are discussed.

Treatment of Shoulder Dislocation with Greater Tuberosity and Glenoid Fractures

Large glenoid fractures are relatively uncommon with shoulder dislocation. Simultaneous glenoid and greater tuberosity fractures with anterior shoulder dislocation are very rare. We report on a 48-year right-handed male who sustained a fall during skiing. He had anterior shoulder dislocation combined with large glenoid fracture and greater tuberosity fracture. He was treated surgically with fixation of the glenoid and greater tuberosity fractures, using two different approaches. The deltopectoral approach with coracoid osteotomy and subscapularis split was used for glenoid fixation. McKenzie's approach was used for greater tuberosity fixation.

Spectrum of Injury to Posterior Glenoid Labral Complex With Emphasis on Diffuse Labral Tears

The posterior glenoid labrum has numerous surrounding structures and any of them can undergo derangement. It is prudent to consider the posterior glenoid labrum complex (PGLC) as a whole rather than simply the labral tissue in isolation when evaluating magnetic resonance imaging (MRI) of the shoulder. The PGLC contains the posterior capsulolabral junction, posterior capsule (posteroinferiorly , the posterior band of the inferior glenohumeral ligament), posterior chondro-osseous junction, posterior chondrolabral junction, posterior glenoid bone, posterior glenoid subchondral bone, posterior glenoid cartilage, posterior labrum, synovial fold (variably seen), and posterior glenoid periosteum (or periosteal sleeve). Noninvasive MRI techniques are the mainstay in evaluating PGLC injury with or without the use of intra-articular gadolinium contrast agents. When using the PGLC model, a spectrum of pathology can be stratified.

Arthroscopic Fixation of Comminuted Glenoid Fractures Using Cannulated Screws and Suture Anchors

We investigate the feasibility of arthroscopic fixation of comminuted glenoid fractures using cannulated screws and suture anchors.We retrospectively review 11 cases of closed comminuted glenoid fractures treated at our institution from August 2010 to May 2013. The 11 patients, 8 males and 3 females, had a mean age of 41 years (range: 27-55 years). The mechanisms of injury were traffic accidents in 9 cases and falls from height in 2 cases. The mean time from injury to surgery was 12 days (range: 3-28 days). All glenoid fractures were confirmed on x-ray and computed tomography. The major fracture fragments were fixed with cannulated screws and the small fragments were fixed with suture anchors.All surgical wounds healed with primary closure and no complications including infection and neurovascular damage were observed. All 11 patients were followed up for a mean of 21 months (range: 14-29 months). Bone union was achieved in all patients with a mean time of 10 months. At the last follow-up, range of motion of the shoulder joint was significantly improved (P < 0.05). Both ASES scores (41.4 ± 24.9, 87.3 ± 13.8) and Rowe scores (28.2 ± 18.6, 93.2 ± 11.2) were significantly increased after the surgery (P < 0.01), indicating significantly improved function and stability of the shoulder joint.Arthroscopic fixation using cannulated screws and suture anchors is feasible for the treatment of comminuted glenoid fractures. This method is minimally invasive and provides good functional recovery with a lower risk of complications.

Current Practice for the Diagnosis of a SLAP Lesion: Systematic Review and Physician Survey

PURPOSE

To evaluate current practice reported in the literature for making a SLAP lesion diagnosis and compare the findings with a survey sent to experienced shoulder surgeons assessing how they make a SLAP diagnosis.

METHODS

We performed a systematic review of articles reporting surgical repair of SLAP lesions, documenting the use of 4 diagnostic areas of evaluation: history, clinical examination, imaging, and diagnostic arthroscopy. A survey was distributed electronically to 175 surgeons with expertise in shoulder surgery. The survey listed common components within the 4 diagnostic areas and asked surgeons to indicate components they used in establishing the diagnosis. The 4 diagnostic areas were ranked from 1 to 4 (most to least important).

RESULTS

Of the articles, 23% reported using all 4 diagnostic areas, 58% used 3 areas, and 19% used 2 areas or fewer. Thirty-five percent did not report history components, 31% did not report clinical examination elements, 27% did not report imaging findings, and 4% did not report arthroscopic findings. Eight percent reported using a comprehensive history and examination but without describing specific symptoms or tests. The most common components reported in the literature were pain (42%), the active compression test (65%), magnetic resonance imaging/arthrography (65%), and tear/unstable biceps-labral complex (27%). A total of 70 surgeons (40%) responded to the survey. More specific history components, examination maneuvers, and imaging/arthroscopy variants were reported on the survey compared with the literature. Diagnostic arthroscopy and history ranked as the most important for a SLAP diagnosis.

CONCLUSIONS

The current literature and practice for making the SLAP diagnosis are variable and inconsistent. The SLAP diagnosis appears to be a clinical impression; however, the criteria described within the literature vary among the evaluation areas and differ from the results of the survey. These types of variability may have a significant influence on consistency and accuracy in making the diagnosis of the SLAP injury, developing the subsequent treatment, and maximizing outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies with cross-sectional survey.

The effect of infraspinatus hypotrophy and weakness on the arthroscopic treatment of spinoglenoid notch cyst associated with superior labrum anterior-to-posterior lesions

PURPOSE

Patients with spinoglenoid notch cyst associated with superior labrum anterior-to-posterior (SLAP) lesions were evaluated. The patients were all treated by arthroscopic cyst decompression combined with SLAP repair. The hypothesis of the study was that the patients who underwent prolonged conservative treatment period prior to surgery would exhibit significant infraspinatus hypotrophy and weakness, and their postoperative clinical and functional outcomes would be less satisfactory.

METHODS

Sixteen patients exhibited positive MRI and EMG findings with clinical signs of weakness and pain. The median age was 40.5 years (range 32-52), and the study group consisted of 11 males and 5 females with a median follow-up period of 26 months (12-48). The median duration of symptoms and conservative treatment prior to the surgical intervention was 3.5 months (1-14). Seven patients in group A exhibited infraspinatus hypotrophy. Group B comprised 9 patients without infraspinatus hypotrophy.

RESULTS

The results of the pre- and postoperative Constant scores, visual analogue scale (VAS) scores, and external rotation strength test rates were compared between groups. They all improved in terms of pain, strength, and function (P < 0.05). Significant differences were observed between the pre- and postoperative external rotation strengths and Constant scores (P < 0.05). However, no significant difference was observed between the pre- and postoperative VAS scores (n.s.). A significant correlation was observed in group A between surgical timing, the preoperative external rotation strength ratio (P = 0.04) and the postoperative VAS scores (P = 0.013).

CONCLUSION

The arthroscopic treatment was satisfactory with good clinical outcomes. Infraspinatus hypotrophy occurred in cases of prolonged surgical duration and significantly affected external rotation strength and functional outcomes.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Glenoid fracture after arthroscopic Bankart repair: case series and biomechanical analysis

To examine whether anchors used in arthroscopic Bankart repair increased the risk of subsequent fracture, six intact polyurethane scapulae and six with three 3.0-mm suture anchors placed along the anteroinferior glenoid were compared. An axial load of 1 mm/s was applied to the anteroinferior glenohumeral joint with a prosthetic humeral head. Outcome measures were force needed for initial fracture and catastrophic failure, percent of anterior glenoid bone loss, and fracture length. With the numbers available, no significant differences could be detected between groups in yield load or maximum load. The anchor group had a significantly larger percentage of bone loss (p < .01) and fracture length (p < .01) compared to the intact group. In this study, anchors did not decrease force needed to fracture but did lead to significantly larger fractures of the anterior glenoid during a simulated dislocation event. Further study using various anchors and techniques is warranted.

Shoulder instability with concomitant bone loss in the athlete

Thorough evaluation of the athlete with persistent shoulder instability and appropriate use of imaging modalities, such as 3-dimensional computed tomography, can help quantify the severity of bony deficiency. Based on obtained imaging and examination, surgical and nonsurgical methods can be considered. In many situations both the humeral- and glenoid-sided bone loss must be addressed. Depending on the extent of bone loss, athletic demands, and surgeon experience, arthroscopic or open surgical options can provide shoulder stability and return athletes to their prior level of activity.

Fracture risk and initial fixation of a cementless glenoid implant: the effect of numbers and types of screws

The initial fixation of an anatomical cementless glenoid component, provided by different numbers and types of screws, and the risk of bone fracture were evaluated by estimating the bone-implant interface micromotions and the principal strains around the prosthesis. Four different fixation configurations using locking or compression screws were tested. Estimation of the micromotions at the bone-implant interface was performed both experimentally, using an in vitro model, and computationally, using a numerical model. Principal bone strains were estimated using the numerical model. Subject variability was included by modelling two different bone qualities (healthy and rheumatoid bone). For the fixation configurations that used two screws, experimental and modelling results found that the micromotions at the bone-implant interface did not change with screw type. However, screw type had a significant effect on fixation when only one screw was used; in this case, a locking screw resulted in less micromotion at the bone-implant interface compared with the compression screw. Bone strains were predicted by the numerical model, and strains were found to be independent of the screw type; however, the predicted strain levels calculated in rheumatoid bone were larger than the strain levels that may cause bone damage for most considered arm positions. Predicted bone strain in healthy bone did not reach this level. While proper initial component fixation that allows biological fixation can be achieved by using additional screws, the risk of bone failure around the screws must be considered, especially in cases of weak bone.

New design of a cementless glenoid component in unconstrained shoulder arthroplasty: a prospective medium-term analysis of 143 cases

The uncemented glenoid implants in total anatomical shoulder arthroplasty are likely to be accused of problems like dissociations, secondary rotator cuff tear, and wear of polyethylene (PE). This work is a clinical and radiological prospective review of 143 cases of anatomical total shoulder arthroplasty using a new metal back uncemented glenoid implant (MB) in order to see if this new implant induces those complications. A total of 143 cases were operated between 2003 and 2011. In a first part, the whole series of 143 cases was radiologically studied in order to quantify the lateralisation induced by the MB implant. In a second study, 37 cases had a mean follow-up of 38 months (24-75, mean 32) and served for the clinical and radiological final study. Pre- and postoperative clinical evaluation was done using the Constant-Murley score and the simple shoulder test from Matsen. The final X-rays served to detect an eventual secondary narrowing of the joint space and to analyse the frequency of radio lucent lines (RLL) and loosenings. Despite a small radiological lateralisation in comparison with the normal contralateral side (0.36 cm, p = 0.02), the clinical results after 2 years were similar to the published cemented glenoid implants series but without any RLL, glenoid loosening or joint narrowing. Some dissociations occured in the beginning and definitely eliminated by a design modification of the PE tray. The discussion tried to show that, despite a still short follow-up, this series is encouraging to continue to use this new MB implant. Different applications of the concept of universality and conversion are discussed, this tray been also the support of a glenosphere in reverse arthroplasty.

Iatrogenic glenoid fracture after brisement manipulation for the stiffness of shoulder in patients with rotator cuff tear

In combined stiffness with rotator cuff tear, the brisement manipulation with or without capsular release has been more common procedure prior to the rotator cuff repair. It is known to be relatively safe and easy procedure with rare complications. However, the present authors found the iatrogenic fracture of anteroinferior portion of glenoid after brisement manipulation during the arthroscopic rotator cuff repair. The patient was followed up with the routine postoperative protocol for rotator cuff repair, which was composed of 4 weeks of protection with abduction brace, passive and active assisted range of motion exercise afterward, and progressive strengthening exercise. Two years after surgery, the patient showed improved clinical score and healing of fracture fragment. However, iatrogenic glenoid fracture should be kept in mind when the brisement manipulation is performed during arthroscopic surgery.

Surgical technique: a minimally invasive approach to scapula neck and body fractures

BACKGROUND

The approach of choice for open reduction internal fixation of displaced fractures involving the scapula neck or body is from posterior. We describe a new approach that minimizes the surgical insult to the soft tissues but preserves the ability to restore alignment and stability to the fracture.

DESCRIPTION OF TECHNIQUE

Based on the fracture pattern, incisions are made along the anatomic bony perimeter to access the scapula borders for reduction and fixation. Since the incisions are centered over sites of "perimeter" fracture displacement of this relatively flat bone, minimal soft tissue retraction and less muscular stripping are necessary, while indirect reduction of the intervening scapula body is accomplished to restore anatomic alignment.

PATIENTS AND METHODS

We retrospectively reviewed seven men with a mean age of 39 years (range, 19-75 years) who underwent open reduction internal fixation of a displaced scapula body or neck fracture using this minimally invasive approach. The minimum followup was 12 months (mean, 16 months; range, 12-23 months).

RESULTS

Six of the seven patients returned to their original occupation/activities. The mean Disabilities of the Arm, Shoulder and Hand score at followup was 8.1 (range, 0-52; normative mean, 10.1). For all parameters, the mean SF-36 scores of the study patients were comparable to those of the normal population. Both strength and motion returned to equivalency with the uninjured shoulder. There were no intraoperative or postoperative complications.

CONCLUSIONS

This novel surgical approach to the scapula allows visualization of fracture reduction without an extensile incision or muscular or subcutaneous flaps and was associated with high functional scores.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.